FAA’S OVERSIGHT OF AMERICAN AIRLINES’ MAINTENANCE PROGRAMS Federal Aviation Administration Report Number: AV-2010-042 Date Issued: February 16, 2010 Memorandum U.S. Department of Transportation Office of the Secretary of Transportation Office of Inspector General Subject: ACTION: FAA’s Oversight of American Airlines’ Date: February 16, 2010 Maintenance Programs Federal Aviation Administration Report Number AV-2010-042 From: Lou E. Dixon Reply to Attn. of: JA-10 Assistant Inspector General for Aviation and Special Program Audits To: Federal Aviation Administrator American Airlines, one of the world’s largest passenger airlines, has not experienced a fatal accident in 8 years. Despite this safety record, we received a complaint in February 2008 alleging that the overall operational reliability of the airline’s aircraft had diminished and that previously reliable aircraft systems were regularly failing. Specifically, the complaint included 10 maintenance-related allegations and highlighted several incidents, including 3 flights that the complainant alleged had experienced cockpit windshield failures. The complaint also included allegations of unacceptably high levels of maintenance deferrals, performance of required aircraft inspections by non-qualified personnel, and failure to perform inspections called for in an aircraft manufacturer’s service bulletin. The complainant also sent the allegations to the Federal Aviation Administration (FAA). FAA Headquarters forwarded the allegations to its American Airlines Certificate Management Office (CMO) in Fort Worth, Texas, for investigation. Given the seriousness of these allegations, we assessed (1) FAA’s oversight of American Airlines’ maintenance program and identified any underlying weaknesses and (2) FAA’s response to the allegations. We conducted this audit in accordance with generally accepted government auditing standards between June 2008 and December 2009. Exhibit A details our audit scope and methodology. Exhibit B lists the entities we visited or contacted. 2 RESULTS IN BRIEF FAA’s oversight of American Airlines’ maintenance program lacks the rigor needed to identify the types of weaknesses alleged by the complainant—at least four of which were confirmed and have potential safety implications. • First, we confirmed the allegation that American Airlines’ maintenance-related events have increased. Further, the National Transportation Safety Board (NTSB) recently found that American’s Continuing Analysis and Surveillance System (CASS)—a system intended to monitor and analyze the performance and effectiveness of a carrier’s inspection and maintenance programs—failed to detect repeated maintenance discrepancies, which, if found, could have prevented an in-flight engine fire that occurred in September 2007. However, during a 2-year period between 2005 and 2007, FAA did not perform required routine surveillance of American’s CASS and reliability programs—two key systems for monitoring carriers’ maintenance programs. While FAA reviewed the carrier’s policies and procedures governing the two systems, it did not determine whether the carrier actually followed them. • Second, we confirmed the allegation that maintenance deferrals increased significantly. From 2004 through the first 5 months of 2008, American’s number of open maintenance deferrals increased by 32 percent, from an average of 298 per day to an average of 394 per day. Despite this increase, FAA only tracked the number of deferrals but did not identify the types of aircraft parts being deferred or the causes of the deferrals. As a result, FAA inspectors missed opportunities to identify potential fleet-wide maintenance issues and put corrective action plans in place. • Third, we confirmed the allegation that American was not following procedures for required maintenance inspections. We found that FAA has not taken appropriate action to address American’s longstanding failure to comply with required maintenance inspection procedures. In late 2005, FAA initiated a System Analysis Team, which made 35 recommendations to improve American’s compliance, but corrective actions for the team’s recommendations made in 2006 are still not complete.1 In December 2007, inspections of repairs made to the aircraft damaged during an in-flight engine fire were performed by a technician whose qualifications had expired—a deficiency that was not discovered until the aircraft was ready to depart with passengers. Following this incident, FAA requested that American submit a comprehensive corrective action plan within 20 days. In September 2008—9 months after FAA’s 1 According to American officials, as of December 2009, they have implemented the majority of the System Analysis Team’s recommendations to improve compliance with RII requirements, with one remaining to be implemented in April 2010. 3 request—American submitted its plan and is continuing its efforts to implement FAA’s 2006 recommendations. • Finally, we confirmed the allegation that American did not implement a Boeing service bulletin2 alerting carriers to problems with aircraft windshield heating systems that could cause the windshield to crack or shatter if left uncorrected. FAA did not identify process weaknesses in American’s maintenance and engineering programs that resulted in the carrier’s failure to perform planned inspections of Boeing 757 windshield heating systems. Further, FAA has yet to finalize and issue an airworthiness directive that would require carriers to address the windshield heating problem—a recommendation NTSB made in 2004. To assess the February 2008 allegations, FAA undertook two reviews. One review was conducted by the CMO for American about 1 month after the allegations were submitted. The other review was conducted by FAA inspectors from outside the CMO utilizing an Internal Assistance Capability (IAC) process to independently review the February 2008 safety allegations.3 However, neither review was comprehensive. The CMO’s review of mechanical reliability focused on only one of the nine systems alleged to have experienced decreased reliability. The independent review did not include work at the air carrier. Instead, the review was performed hastily over 1 weekend and focused on the work already performed by the CMO, such as inspection reports filed by CMO inspectors. As a result, the IAC team reached a number of the same faulty conclusions made by the CMO. Additionally, the IAC’s June 2008 recommendations have not been acted upon because, according to CMO managers, they did not receive a copy of the IAC’s final report until June 2009. Based on our findings, we are making several recommendations to enhance FAA’s oversight in key maintenance areas at American and improve its processes for assessing safety allegations. BACKGROUND In 1998, FAA implemented the Air Transportation Oversight System (ATOS), a data-driven, risk-based approach to air carrier safety oversight. ATOS was designed to shift inspectors away from the inspection method they had used for over 30 years, which focused on whether air carriers were complying with regulations, to an approach that proactively assessed risks within air carriers’ 2 Implementing the service bulletin was not required. However, service bulletins often highlight safety issues that lead to the issuance of an airworthiness directive. 3 The IAC was developed in response to an OIG recommendation: OIG Report Number AV-2007-080, “FAA’s Actions Taken To Address Unsafe Maintenance Practices at Northwest Airlines,” September 28, 2007. OIG reports are available on our website: www.oig.dot.gov. 4 maintenance and operations systems. Under ATOS, FAA inspectors are to use data analysis to focus their inspections on areas that pose the greatest safety risks and to shift the focus of those inspections in response to changing conditions within air carriers’ operations. CASS and reliability are two of the key air carrier systems that inspectors assess under ATOS. FAA regulations require some air carriers to have a CASS to assess maintenance performed on the carrier’s aircraft.4 Although not required, air carriers may have an FAA-approved reliability program, which monitors failure rates of aircraft components with the goal of achieving improved operational performance. Air carrier personnel enter reliability program data into CASS for monitoring the effectiveness of air carriers’ inspection and maintenance programs. FAA inspectors are responsible for determining whether these maintenance and monitoring systems are working effectively through routine ATOS surveillance. The February 2008 complaint raised serious questions about the effectiveness of American’s CASS and FAA’s oversight of the air carrier’s maintenance program. Specifically, the complaint included 10 maintenance-related allegations that indicated an overall deterioration in the airline’s operational reliability. The complainant’s 10 allegations are listed below. February 28, 2008, Allegations Against American Airlines • Maintenance-related delays, cancellations, and diversions have increased. • Minimum Equipment List (MEL) deferrals have increased, and MEL authority has been abused. • A Boeing service bulletin that could have prevented some cockpit windshield failures was not implemented. • Certain Functional Check Flights (post-maintenance test flights) were eliminated. • Maintenance check intervals were changed, resulting in fewer maintenance checks. • Spare parts inventories were reduced. • Required inspections of an aircraft repaired after a September 2007 engine